Healthcare Provider Details

I. General information

NPI: 1215383450
Provider Name (Legal Business Name): JACOB DUNN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 10TH AVE STE 310
COLUMBUS GA
31901-3607
US

IV. Provider business mailing address

1900 10TH AVE STE 310
COLUMBUS GA
31901-3607
US

V. Phone/Fax

Practice location:
  • Phone: 706-641-0104
  • Fax: 706-641-0106
Mailing address:
  • Phone: 706-641-0104
  • Fax: 706-641-0106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number91277
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: